OBJECTIVES:
- Determine the basic differences between benign and malignant skin lesions by review of clinical findings and microscopic pathology. Learn about some of the very common skin lesions, what causes them, and what their courses are.
CASE 1
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History:
- This 63-year-old man has multiple raised velvety coin-like tan to brown lesions over the face and upper chest that have a "stuck on" appearance. They have appeared over the past 5 years and have slowly enlarged.
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Questions:
- What is the diagnosis?
- What is the natural history of this lesion?
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CASE 2
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History:
- A 19-year-old man has had severe outbreaks of pimples (comedones appearing as "blackheads" and "whiteheads"), some of which have enlarged and become pustules. These lesions have appeared on his face, upper chest, and mid-upper back since adolesence.
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Questions:
- What causes this condition?
- What is the course of this disease?
- What is the role of hygiene and diet?
- What pharmacologic therapies are available?
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CASE 3
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History:
- This is a lesion from the ear of a 32-year-old African-American man who had a history of just a minor cut a few months ago, but the scar that formed afterwards is now quite prominent.
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Questions:
- What is the diagnosis?
- Why does this happen?
- Name some related lesions involving fibroblastic proliferation.
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CASE 4
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History:
- Just about everyone has at least one of these. They may be flat and pigmented, or they may be pale and nodular, but they are never very large and they hardly seem to enlarge as you get older.
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Questions:
- What is the diagnosis?
- Are these lesions premalignant?
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CASE 5
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History:
- A 48-year-old rancher (stockman) noted a "mole" on his arm that seemed to be getting larger and then changed color in the past 3 months. He went to his physician who then referred the patient to a surgeon, who removed the lesion and 3 sentinel lymph nodes.
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Questions:
- What is the diagnosis?
- From examination of the lesion in the image, how could you say something about the prognosis?
- If the sentinel nodes had no disease, what is the significance?
- The patient surfs the World Wide Web and finds several sites touting experimental 'cures' for this condition. What should you tell him?
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CASE 6
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History:
- This 41-year-old former lifeguard spent a lot of time on the beach. She developed multiple scaling, erythematous lesions on the face that were 0.5 to 1 cm in size. One of the larger lesions that was ulcerated and had an indurated border was excised.
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Questions:
- What is the diagnosis?
- Why did this lesion develop?
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CASE 7
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History:
- This 66-year-old man is an avid sport fisherman who operates a charter boat out of Islamorada in the Florida Keys. He has noted a slowly enlarging nodule on the outer helix of his right ear. His physician noted that the nodule was pearly pink, 1.1 cm in diameter, with a central umbilicated ulcerated area.
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Questions:
- What is the diagnosis?
- What patterns of growth can be seen with this lesion?
- What is the prognosis?
- Worst case scenario: what would you do if the patient had seen another physician who did not properly treat a basal cell carcinoma of the eyelid, and now the patient may lose the eye?
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CASE 8
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History:
- This 25-year-old man has multiple firm nodules, some of which are up to several cm in size and are disfiguring. Also noted on physical examination are ten light brown macules with smooth borders averaging about 2 to 3 cm in size scattered over the trunk and arms.
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Questions:
- What is the diagnosis?
- What is the natural history of this process?
- What is the genetic basis for this lesion?
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